The article describes
the prevalence of musculoskeletalpain according to socio-demographic and occupational
variables among elementary school teachers. A cross-sectional study included
all 4,496 school teachers of the municipal elementary education network of Salvador,
Bahia, Brazil. There was a high prevalence of musculoskeletal pain in lower
limbs (41.1%), upper limbs (23.7%) and back (41.1%). The overall prevalence
of musculoskeletal pain related to any of the three body segments was 55%. Musculoskeletal
pain was more prevalent in the three body segments investigated: among women,
the elderly, those with high-level school education, married, with three or
more children, and who had worked over fourteen years as teachers. The prevalence
of musculoskeletal pain was associated with the following occupational variables:
working over five years at the school, high level of physical exertion, not
having a paid activity other than teaching, and reporting heat in the classroom.
The findings draw attention toward the need to adopt public policies to improve
the working conditions of teachers.

Work is essential
in the lives of men and women; nonetheless, it can become a health hazard when
it is carried out in an inappropriate way. Some groups of workers, due to occupational
characteristics, are more exposed to work related musculoskeletal pain1.
Teachers stand out among these groups. Sometimes, teaching is carried out under
unfavorable circumstances, in which teachers mobilize their physical, cognitive,
and affective capacity to reach teaching production objectives, over demanding
or generating over effort of their psycho-physiologic functions2.
If there is not enough time for recovery, pain symptoms that account for the
high levels of absenteeism due to health conditions in this group of workers
are triggered or prompted. Thus, teaching leads to stress, with consequences
to physical and mental health and with an impact on professional performance1,3.

Social transformations,
educational reforms and new teaching models have influenced current conditions
of teaching, leading to changes in the profession. Therefore, teachers go from
a stable and relatively safe status to a state of instability at work, subsequent
to new, precarious and unregulated working modes2.

In the past, the
educational sector went through changes that led to the escalation of teachers'
activities and to increasingly precarious conditions in work relations. Cuts
in funding for education reflect the new social organization processes in the
globalized age. In face of market demands in the economic globalization process,
educational institutions have begun to face new obstacles, especially in relation
to meeting their educational commitments appropriately and satisfactorily. The
process generates intense conflict for teachers, which are also worsened by
the social demands of teachers' role: on one hand the demands of quality teaching
and positive results; on the other hand, in a scenario of mass production, scarcity
of material and human resources. These opposite movements push toward a dilemma:
the generation of positive results without appropriate and necessary tools.
This scenario tends to generate lack of prestige and underrating of teachers,
already overloaded by the need to respond to the new demands of Education4.

Growing responsibilities
and demands on teachers are the consequence of a fast historical process in
Brazilian society. One of the reflexes of these transformations was called teaching
"malaise", represented by a set of health hazards due to, among many factors,
not adapting to the new demands of the profession2.

In the past decade,
different studies described the most prevalent health problems among teachers,
in which musculoskeletal disorders, voice problems and psychiatric disorders
stand out1,5-10.

Musculoskeletal
pain or painful feeling has been mentioned in several studies among teachers
as a relevant health problem, and conditions due to musculoskeletal system disorders
are the main causes of absenteeism and of professional diseases in this category11.
Everyone, excluding individuals with congenital insensitivity, has already felt
pain sometime in their lives. However, when symptoms continue, they become a
problem, a reason for reducing work activity, work leaves and absence, in addition
to the possibility of developing depression12. Several socio-demographic,
psychosocial, physical, and organizational factors are related to triggering,
developing, and maintaining musculoskeletal pain 13.

Medical and social
costs due to these problems have grown incessantly in past years and currently
reach figures of roughly billions of dollars in several countries, representing
a significant impact on health and quality of life of workers14.
Therefore, the analysis and appropriate determination of the problem, and the
investigation of its associated factors, are relevant to design measures that
may intervene on the problem.

This study aims
to describe the prevalence of musculoskeletal pain according to socio-demographic
and teaching characteristics among teachers of the municipal school network
of Salvador, Bahia, Brazil.

METHODS

Cross sectional,
descriptive, epidemiological study on the working conditions and health of teachers
of the municipal teaching network of Salvador. The municipal teaching network
encompasses pre-school, elementary school level I (1st to 5th
grade) and elementary school level II (6th to 9th grade).
A survey including all teachers of the municipal school network of Salvador
was performed during a teacher registration recall, in 2006.

The data collecting
tool used comprised blocks of questions related to socio-demographic information
aimed at characterizing teachers; their work in the municipal network of Salvador;
conditions in the school work environment; mental health; vocal health and main
health problems reported by teachers. The questionnaire was given to teachers
in a sealed and anonymous envelope. The envelope, in addition to the questionnaire,
also had a letter from the Municipal Secretary of Education and Culture, asking
teachers to participate in the survey and informing that it was a voluntary
act in which teachers should not identify themselves.

The dependent variable,
frequency of musculoskeletal pain, was investigated in three body regions: lower
limbs: "leg pain"; upper limbs: "arm pain", and back: "back pain". The frequency
of pain was measured on a Likert type scale: 0=never; 1=rarely; 2=not very frequently;
3=frequently and 4=very frequently. In the study, musculoskeletal pain was taken
into account when the teacher reported pain as "frequently" or "very frequently",
for each body region mentioned above.

The initial descriptive
analysis considered socio-demographic variables, variables related to teaching,
and variables related to work load.

The prevalence
of musculoskeletal pain was estimated according to socio-demographic variables
(age, sex, marital status, schooling, having children, and number of children),
characteristics of teaching (time working as a teacher, time working at school
in which teacher answered questionnaire, work shift, number of classes, average
number of pupils per class, weekly schedule, and other paid activity besides
teaching), and work loads (physical loads: heat; ergonomic loads: furniture
and size of classrooms). Prevalence ratios and respective 95% confidence intervals
were calculated. Pearson's chi-square test was used to assess statistical significance,
adopting α=5%.
The prevalence of musculoskeletal complaints according to time working was adjusted
by age group using the Mantel-Haenszel method.

The present study
followed the recommendations of resolution 196/96 of the National Health Council.
Teachers were assured confidentiality of data provided, and information was
used exclusively to meet the objectives of the study. Under no circumstances
were teachers identified, thus guaranteeing information confidentiality. The
Project was approved by the Research Ethics Committee of Maternidade Climério
de Oliveira of Universidade Federal da Bahia, report #83/2007.

RESULTS

Of the 4,697 teachers
of the municipal school network, 4,496 were included (95.1% response rate).
Women represented most of the population studied (92.0%); 47.9% were 40 years
old or over, ranging from 18 to 69 years; the mean age was 40.0 ± 9.4 years.
Time working as a teacher and at the school ranged, respectively, from 1 to
45 years (mean of 14.4 ± 8.4 years) and from 1 to 37 years (mean of 6.5 ± 6.3
years). There were 68.3% of teachers at Elementary Level I. Teachers had, on
average, 2.1±1.7 classes and 31.2 ± 5.8 students per classroom. Approximately
14% of teachers worked at another municipal school and 31.9% at a school of
another teaching network.

The prevalence
of musculoskeletal pain (MSP) was 41.1% for lower limbs, 41.1% for back, and
23.7% for upper limbs (Table 1). The overall prevalence of
MSP related to anyone of the three body segments was 55%: 19.7% reported pain
only in one of the three body segments analyzed, 19.9% in two segments, and
15.4% in three segments.

The prevalence
of MSP was higher among those who reported back and lower limb pain together
(29.8%). Simultaneous back and upper limb MSP was reported by 18.5% of the sample,
and upper limbs and lower limbs by 17.7% of the teachers.

The prevalence
of musculoskeletal pain in the population studied was higher among women than
among men for the three body segments: lower limbs, upper limbs and back (Table
2). Regarding age group, an increase in MSP with age was observed (Table
2). Teachers with high-school education had a higher prevalence of lower
limb pain (46.4%) than those with college level schooling. Higher prevalence
of upper limb and back pain were observed among widowed, separated, and divorced
teachers. Having more than three children was positively associated with MSP
(Table 2).

Teachers with fourteen
or more years of profession had a higher prevalence of MSP at statistically
significant levels in the segments analyzed (Table
2). When adjusted for age, the association between time working and MSP
in the three segments studied remained positive (Table 3).

The identification
of musculoskeletal pain in the body segments studied according to variables
related to teaching and work loads is presented in table
4. More time working at the school in which the questionnaire was answered
(> 5 years) associated positively with musculoskeletal pain, at statistically
significant levels. After adjusting for age, time working at school remained
significantly associated with MSP in upper limbs (p < 0.001) and back (p
< 0.01), and had a limited significance level (p < 0.06) for lower limbs.
The prevalence of MSP in lower limbs was associated in a statistically significant
way (p < 0.05 or less) with working more than 5 years, a weekly schedule
greater than 40 hours, having another paid activity in addition to teaching
(as a protective factor), a lot of physical exertion and heat in the classroom.
Complaints of MSP in upper limbs were significantly associated with working
more than 5 years, more than 30 students per class, weekly schedule greater
than 40, having another paid activity (as a protective factor), a lot of physical
exertion and heat in the classroom. Back MSP was significantly associated with
working more than 5 years, intense physical exertion, inappropriate furniture,
and heat in the classroom.

DISCUSSION

In the population
studied, there was a predominance of women with a mean age above 40 years, with
complete college education, married and with a child. Such findings are similar
to those of other studies carried out with teachers5,6,8,10. The
mean time working as a teacher was 14.4 years, relatively higher in comparison
to the studies of Reis et al.8 and Silvany Neto et al.5,
in which the mean time was 10.4 and 11 years, respectively. Gasparini et al.10,
in a study performed with teachers of the municipal network of Belo Horizonte,
found a mean working time of 16.6 years, higher than the findings for teachers
of Salvador.

The findings confirm
the higher percentage of female teachers in the educational sector. The scenario
reflects the growth of the sector that occurred as of the second half of the
20th century, when there was the inclusion of many workers in the educational
area. The introduction of women in the working world, as teachers and nurses,
was conceived as a "care" activity and continuity of domestic activities6.
In this fashion, education is a professional field currently occupied predominantly
by women. Women are the majority of the category. According to a study performed
by UNESCO15 on the profile of teachers in Brazil, 81.3% of teachers
were women.

Differences between
working conditions of men and women have been mentioned in different studies
with teachers, in that women are less qualified, earn lower wages, and have
lower levels of control over work in comparison to men, and higher levels of
demands9. These characteristics have also been described, in turn,
to be associated with acquiring more physical and psychological diseases. Even
though women prevail in teaching activities, they still get less qualified working
positions, with lower wages and low social status 5,9.

The prevalence
of MSP was higher among women, in the three body segments studied. Other studies
have found a lower prevalence of MSP in women than those found herein16-18.
However, it should be pointed out that the higher prevalence of MSP in women
in comparison to men remained the same in these studies. In a study performed
with the inhabitants of the province of Quebec16, 20.4% of women
were observed to report musculoskeletal pain in lower limbs, 22.3% in upper
limbs and 30.4% in back. In the study of Kjellberg and Wadman18,
performed in Sweden, only 19% of pain occurred in lower limbs. Social and economic
differences between Brazil and the countries of the studies mentioned, the way
in which work is organized, the demands faced by workers and the protective
factors involved2 contribute to the differences observed in comparison
to the present study.

The association
between MSP and age over 40 years, in the three segments analyzed, may be explained
by the natural wear of the body. However, this process may be influenced by
the work environment, by the kind of activity developed and by the organization
of work6. In this way, age would be a factor associated with the
occurrence of pain. Reis et al.3 discussed that teachers with more
professional experience are less susceptible to the negative effects of work
on health; on the other hand, if the time in the profession was marked by restriction
to gaining experience as a teacher, exposure may be associated with adverse
health situations.

Findings strengthen
the assumption that prolonged exposure to teaching is associated with a higher
occurrence of MSP. The finding does not change when association estimates are
adjusted by the effect of age. It is noteworthy to mention, however, that musculoskeletal
pain was reported by 37.5% (lower limbs) to 37.2% (back) of teachers with up
to 29 years of age. The fact is concerning, because younger teachers seem to
be having pain early. A study showed that younger workers face greater work
demands, being exposed to risk factors, as they take over more activities and
tasks in the beginning of the career19.

In the present
study, teachers with high-school level reported more musculoskeletal pain in
comparison to those with complete college level. Teachers with less schooling
could be in different working conditions because most of them are still being
trained (attending college), which would add new demands to teaching activities.

The teachers of
Salvador with three or more children reported more MSP than those with one or
two children. These findings are consistent with findings in the literature,
which mention that having more children corresponds to more time dedicated to
taking care of children; possibility of more psychological stress; and need
of a higher work load to increase family income20.

Time working as
a teacher and time teaching at the school where the interview was done showed
association with MSP, in the three body segments investigated. The changes in
the Brazilian educational system that occurred in past decades brought about
new demands to the teachers' category and increasingly precarious working conditions.
These unfavorable conditions may be factors influencing the occurrence of MSP,
as Malchaire, Cock and Vergracht have appointed13. Therefore, the
prolonged exposure to these unfavorable conditions becomes a health risk factor.

Musculoskeletal
pain was more frequent in teachers with a 40-hour weekly schedule and who worked
on two or more shifts, although not all differences observed were statistically
significant. Such characteristics suggest that the long and, probably, intense
workday could contribute to the occurrence of the event. Teachers' overworking
has been mentioned in other studies, both for pre-school and college teachers5-8,10,21-23.

MSP was more prevalent
in teachers with classes with more than 30 students, although, also for this
variable, results were statistically significant only for upper limbs.

Findings related
to the number of classes and of students, even if the differences observed did
not reach statistical significance levels, suggest that the increase in the
number of classes and of students leads to additional activities for the teacher
(planning and correcting school activities; more attention), increasing the
occurrence of MSP. UNESCO and ILO (International Labor Organization) recommend
not surpassing 25 students per class24. This scenario directly influences
the quality of teaching, leading to worse learning conditions for students and
health hazards to teachers.

Teachers who also
worked in another school had a higher prevalence in comparison to those who
worked in only one school. However, those with another paid activity besides
teaching had a significantly lower prevalence of MSP than those who did not.
These findings strengthen the assumption that teachers are submitted to work
conditions that favor the emergence or maintenance of musculoskeletal pain.
The situation could be favored by the worker being engaged in an activity other
than teaching, and therefore exposed to work conditions different than teaching,
and which could be more favorable. Seen from this perspective, the association
between having another activity and MSP protected some of the segments analyzed,
reaching statistically significant levels for lower limbs and upper limbs.

High physical exertion
showed to be an important factor associated with MSP. These findings are consistent
with Malchaire, Cock and Vergrocht's study13 that highlighted, among
other factors studied, physical work loads as important factors that contribute
to the occurrence of MSP. Barros et al.25 reported that the work
of teachers involves a considerable physical load, established by the educator
remaining in the orthostatic position during up to 95% of activities, with varied
levels of flexion of the backbone. In the study developed by Delcor et al.6,
among physical exertions during teaching, time standing up was relevant. Standing
up is not the only factor contributing to MSP, but other situations such as
carrying material to school or to the classroom, installation of equipment/teaching
resources, walking inside and outside the school may be associated with the
occurrence of MSP.

Among the work
environment conditions analyzed, there was an association between heat and MSP
in lower limbs, upper limbs and back. Studies have shown that there is a correlation
between carrying out activities and the work environment. Adverse or uncomfortable
conditions may lead to future harm to the health of teachers26,27.
Excessive exposure to high temperature may lead to disorders such as heat exhaustion,
thermoplegia, and cramps. The likelihood of developing these disorders increases
with high humidity and high physical exertion. Even if immediate morbid states
are not presented, the ongoing thermal overload, in the long term may have deleterious
effects on health.

In relation to
ergonomic loads, teachers' mention of inappropriate furniture in the classroom
was observed to have a positive association with MSP for back. In the study
of Araújo et al.7, 59.3% of university teachers reported working
in an inappropriate body position. The adoption of inappropriate postures by
teachers, influenced mainly by environment with inappropriate conditions, may
contribute to the emergence of MSP. In the study by Chiu and Lam29,
carried out with high school teachers in Hong Kong, posture with flexion of
the head was an important factor associated with MSP in the neck and upper limbs.
The lack of chairs and tables in sizes and shapes appropriate for teachers obliges
them to develop positions unfavorable to the musculoskeletal system. Inappropriate
chairs make teachers sit without back support, with excessive flexion of knees
and hips (in the case of low chairs), and flexion of the trunk to write and
read texts on the table or even for student roll call, and without support for
upper limbs 30.

Final Considerations

This paper addressed
musculoskeletal pain in three different body regions. The findings of the study
strengthen the assumption that characteristics of certain work activities have
negative effects on the health of workers. The teachers herein reported a high
prevalence of musculoskeletal pain in upper limbs, lower limbs, and back. The
association between socio-demographic and occupational factors was also analyzed.
The identification of these factors may contribute to the adoption of public
policies aimed at preventing disease and promoting the well-being of this professional
category.